Adult Health - Archer Review (6/8) -Respiratory and Visual/ auditory

Choice B is correct. A client who experiences a pneumothorax may initially experience shortness of breath and chest pain. When the pneumothorax increases in size the client will display an increased respiratory rate, cyanosis, diminished breath sounds, and subcutaneous emphysema.

A 32-year-old man comes into the emergency department after being hit by a baseball bat in his chest. The nurse would suspect a pneumothorax because of which sign? A. Decreased respiratory rate B. Diminished breath sounds C. Presence of a barrel chest D. A sucking sound at the injury site

Choice B is correct. In the absence of an emergency, the cuff should never be deflated during the initial 24-hour period. In order to minimize the risk of bleeding around the insertion site for the initial 24 hours following a tracheostomy, the nurse must minimize the number of tracheostomy manipulations that occur. Each time a tracheostomy tube is manipulated, there is an opportunity for complications and associated morbidity. Every manipulation carries the risk of trauma to the tracheostomy wound and accidental decannulation.

A 70-year-old client was admitted for pneumonia. The client developed acute respiratory distress syndrome resulting in respiratory arrest, requiring an endotracheal tube. Attempts to wean the client from mechanical ventilation were ineffective, and the client received a tracheostomy. How can the nurse minimize bleeding around the insertion site for the first 24 hours following tracheostomy? A. Deflate the cuff for ten minutes every other hour instead of five minutes every hour B. Avoid manipulating the tracheostomy, and do not deflate the cuff C. Monitor for signs of crepitus and, if noted, report these findings immediately to the health care provider (HCP) D. Change the tracheostomy dressing PRN using 1/2 strength hydrogen peroxide to clean the site

Choice B is correct. The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space.

A client is diagnosed with a spontaneous pneumothorax which results in the need to insert a chest tube. What is the best explanation for the nurse to provide this client? A. "The tube will prevent you from having chest pains." B. "The tube will remove excess air from your chest." C. "The tube controls the amount of air that enters your chest." D. "The tube will seal the hole in your lung."

Choice A is correct. Changes in breath sounds indicate that the client has responded to the albuterol nebulizer. Upon the initial auscultation by the nurse, there were nearly absent breath sounds, indicating severe airflow obstruction was present. Thirty minutes after the medication administration, diffuse inspiratory and expiratory wheezes throughout the lung fields demonstrate that airflow has improved (even though the lung fields remain partially obstructed).

A client was admitted for an acute exacerbation of asthma. Auscultation findings reveal nearly absent breath sounds, and an albuterol nebulization treatment was promptly administered. Thirty minutes later, upon auscultation, the nurse hears diffuse inspiratory and expiratory wheezes throughout the lung fields. This finding means: A. There is increased airflow B. There is no improvement in the airflow C. There is worsening of the condition D. The airflow issue was not addressed

Choice B is correct. This statement is correct. The LAIV is a nasal spray flu vaccine approved for use in healthy non-pregnant people, 2 through 49 years old. Individuals who are pregnant, immunocompromised, younger than 2, or older than 49 should not receive this vaccine. The LAIV contains weakened influenza viruses that are cold-adapted, which means they are designed to only multiply at the cooler temperatures found within the nose and not the lungs or other areas where warmer temperatures exist. No influenza vaccine causes influenza. The LAIV has demonstrated a more robust immune response when compared to the IIV.

A nurse has attended a continuing education conference about seasonal influenza. Which of the following statements would indicate a correct understanding of the conference? A. "Oseltamivir therapy should be started 96 hours after the onset of symptoms." B. "The live attenuated vaccine (LAV) is for healthy non-pregnant individuals, 2 through 49 years old." C. "Individuals who are pregnant should not receive the inactivated influenza vaccine." D. "Visitors should be provided face shields when entering a client's room."

Choices B and E are correct. Smoking is a major risk factor for the development and progression of COPD. Encouraging smoking cessation is an essential intervention to prevent further lung damage and improve the client's respiratory status. Pursed-lip breathing is a breathing technique that can help clients with COPD improve their breathing efficiency and control dyspnea.

A nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD). Which of the following interventions should the nurse implement for this client? Select all that apply. Administer a long-acting bronchodilator for acute dyspnea. Encourage smoking cessation. Provide oxygen therapy at a rate of 4 liters per minute. Instruct the client to lie down in a supine position. Teach pursed-lip breathing technique.

Choice A is correct. Aspiration of salt water or fresh water can lead to surfactant washout, disrupting the alveolar-capillary membrane and increasing its permeability. Surfactant reduces surface tension within the alveoli, increases lung compliance and alveolar radius, and decreases the work of breathing. The loss of surfactant destabilizes the alveoli, causing increased airway resistance. Following the aspiration of salt water or fresh water and the associated surfactant washout, the client is at significant risk of pulmonary edema.

A nurse is caring for a client who recently experienced a non-fatal drowning. The client is now having pulmonary edema. The nurse understands that pulmonary edema is the result of which process? A. Water washing out the alveolar surfactant. B. Water introducing bacteria into the lungs and causing infection. C. Decreased intrathoracic pressure in the lungs. D. A sudden change in temperature within the lungs.

Choice B is correct. Tidaling in the water seal chamber and intermittent bubbling are expected for a client with a pneumothorax. If tidaling and intermittent bubbling have stopped, it could indicate a positive finding, such as the resolution of the pneumothorax. Considering this client had this device placed three hours ago, the resolution of the pneumothorax is unlikely. A more likely scenario is that a portion of the tubing is kinked or obstructed, which has stopped the tidaling in the water seal chamber. The easiest, least invasive, and quickest assessment the nurse can perform while walking to the client's bedside is a visual assessment of the chest tube tubing to assess whether a kink is present in the chest tube tubing, resulting in a ceasing of the tidaling. Therefore, Choice B is correct.

A nurse is caring for a client who, within the last three hours, received a pneumothorax diagnosis and had a chest tube placed. Upon assessment, the nurse observes no tidaling in the water seal chamber. Which of the following actions would be most appropriate for the nurse? A. Auscultate the client's lung sounds. B. Assess the tubing for any kinks. C. Instruct the client to cough and deep breathe. D. Check the amount of water in the suction control chamber.

Choice C is correct. Impaired gas exchange is the priority nursing diagnosis for a client with chronic obstructive pulmonary disease (COPD) based on Maslow's hierarchy of needs. The nurse should implement measures that ensure adequate oxygen and carbon dioxide exchange for the client. Impaired gas exchange falls under the physiological needs level of Maslow's hierarchy of needs. In prioritization questions, physiological needs must be prioritized over all other needs. Therefore, this is the priority nursing diagnosis.

A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Which of the following would be the priority nursing diagnosis for this client? A. Activity intolerance B. Ineffective coping C. Impaired gas exchange D. Self-care deficit

Choice D is correct. CO poisoning requires aggressive oxygenation at a FiO2 of 100%. A nonrebreather is the only delivery device to provide a FiO2 level of 100% and is used for a client with CO poisoning.

The nurse is caring for a client with carbon monoxide (CO) poisoning. The nurse anticipates administering oxygen via A. nasal cannula. B. venturi mask. C. simple mask. D. nonrebreather mask.

Choice B is correct. When caring for a client requiring a sputum culture, the sputum sample should be obtained before initiating antibiotic therapy. Obtaining the sputum sample prior to initiating antibiotic therapy allows for accurate detection of the organism(s) causing the infection through the sputum culture.

Following a persistent cough, chills, and fever, a client was admitted for a possible respiratory infection. The admission orders include a regular diet, vital signs every 4 hours, ampicillin 250 mg PO every 6 hours, and sputum culture. Before beginning antibiotic therapy, the nurse should perform which of the following? A. Provide the client a full meal B. Collect the sputum sample C. Assess the client's vital signs D. Assess the client's oxygen saturation

Choices A, C, and D are correct. Respiratory infections are common in acute pancreatitis due to retroperitoneal fluid pushing the diaphragm upwards and causing the client to take shallow abdominal breaths. Assisting the client to change positions frequently, encouraging deep breathing, coughing exercises, and positioning clients for maximum chest expansion would all be preventative interventions to reduce the risk of respiratory infection.

The client is diagnosed with acute pancreatitis. Which preventative intervention should the nurse implement to reduce the client's risk of developing a respiratory infection? Select all that apply. Assist the client to turn and reposition frequently Document the respiratory rate and oxygen saturation Place the client in a semi-fowlers position Encourage deep breathing and coughing. Obtain a prescription for prophylactic antibiotics

Choice B is correct. Orthopnea is shortness of breath that occurs when lying flat, causing the person to have to sleep propped up in bed or sitting in a chair. Asking the client how many pillows they use to sleep on is a way to assess if the client has been educated about measures to prevent orthopnea. COPD causes blocked or narrowed airways that make breathing more difficult. Clients may experience symptoms like wheezing, coughing, mucus production, and tightness in the chest. Smoking or exposure to harmful chemicals can cause COPD. Orthopnea is a common symptom of COPD clients.

The client with chronic obstructive pulmonary disease (COPD) reports trouble sleeping at night. Which question is most important for the nurse to ask? A. "What do you eat before you go to bed? B. "How many pillows do you sleep on at night?" C. "Have you always been a light sleeper?" D. "Is your partner snoring and keeping you awake?"

Choice B is correct. The nurse should meet the client upon arrival to the unit and should describe the layout of the room using a focal point and directions. The nurse should include information about calling for help when needed. These measures will reduce the client's anxiety as well as promote the client's independence and safety.

The med-surge nurse receives a report on a client who is legally blind. Which action by the nurse would be most likely to reduce this client's anxiety? A. Assign the client to a private room. B. Orient the client to their room. C. Request for a sitter to be assigned. D. Instruct the UAP to check on the client frequently.

Choice C is correct. The client should not eat or drink immediately after the procedure. Topical anesthesia is typically applied to the tongue, nasopharynx, and larynx to allow the bronchoscopy procedure. Following the procedure, the client will be kept NPO (nothing by mouth) until the anesthetic wears off and the client's cough and gag reflex return. Upon the return of those protective reflexes, the client will be provided ice chips and small sips of water before slowly progressing into a regular diet to minimize the risk of aspiration.

The new nurse is educating a client who is scheduled for a bronchoscopy. Which of the following requires follow-up by the charge nurse? A. Educates the client regarding a potential sore throat after the procedure. B. Tells the client that they may be lying down or sitting for approximately 30-60 minutes during the procedure. C. Educates the client that they may be able to eat immediately after the procedure. D. Informs the client they must not eat or drink for six hours before the procedure.

Choice B is correct. A thoracentesis is best performed with the client sitting upright and leaning slightly forward with arms supported. Unless there is a large volume of fluid in the pleural space, thoracentesis usually takes 10 to 15 minutes. During this time, most clients sit quietly on the edge of a chair or bed with their head and arms resting on a pillow positioned on a bedside table. Semi-Fowler's position is not utilized.

The new nurse is preparing a client for a thoracentesis. Which of the following actions by the new nurse requires follow-up by the charge nurse? A. Ensure the client has provided informed consent. B. Place the client in semi-Fowler's position. C. Instruct the client to remain still when the needle is inserted. D. Monitor for tachypnea, dyspnea, and cyanosis.

Choice C is correct. Pulmonary edema is a medical emergency that may cause a client to develop respiratory arrest. Immediate treatment measures for pulmonary edema include providing oxygen at its highest concentration via a nonrebreather mask. This device may deliver up to 95% FiO2. If this is ineffective, the provider may consider BiPAP, CPAP, or intubation with mechanical ventilation.

The nurse cares for a client experiencing acute pulmonary edema and has a pulse oximetry reading of 86% on room air. Which oxygen delivery device should the nurse apply to the client? A. Simple facemask B. Nasal cannula C. Nonrebreather mask D. Partial rebreather mask

Supplemental oxygen Chest radiograph (x-ray) 0.9% saline infusion Laboratory work (CBC, CMP) Blood cultures Acetaminophen Albuterol via nebulizer

The nurse develops a care plan for this client and anticipates which orders and prescriptions from the physician? Select all that apply Supplemental oxygen Chest radiograph (x-ray) 0.9% saline infusion Hourly blood glucose Laboratory work (CBC, CMP) Blood cultures Acetaminophen Strict bed rest Albuterol via nebulizer Bedside thoracentesis

Choice B is correct. Bilateral breath sounds indicate that both the clients' lungs have expanded, which is the procedure's objective. A pneumothorax produces diminished or absent breath sounds in the affected lung. Once the chest tube has exerted its desired effect, the lung sounds should become clear.

The nurse has just finished assisting the surgeon with inserting a chest tube in a client with a pneumothorax. Which assessment finding indicates that the procedure has produced its desired effect? A. Consolidation is seen in the chest x-ray. B. Clear breath sounds are auscultated bilaterally. C. There is rapid bubbling in the suction chamber of the chest drainage system. D. There is crepitus at the insertion site.

Choice B is correct. A crucial part of mitigating the symptoms of obstructive sleep apnea is for a client to lose weight. Weight reduction is a pivotal part of the treatment plan for an individual with OSA, as being overweight or obese causes fat deposits in the upper airways. Reducing these fat deposits improves muscle activity and allows for better ventilation. The client stated that they plan on exercising 150 minutes a week is a favorable response because that is the national recommendation.

The nurse has provided education to a client diagnosed with obstructive sleep apnea (OSA). Which client statement would indicate a correct understanding of the teaching? A. "I should use an antiseptic mouthwash immediately before going to bed." B. "I will plan on exercising at least 150 minutes a week." C. "I have been reading about the potential for me needing supplemental oxygen overnight." D. "I will sleep flat on my bed without any pillows."

Choice B is correct. In Asian American culture, asking personal questions during the initial meeting is uncomfortable and indiscreet. The nurse can put off this assessment until the patient is already relaxed and comfortable.

The nurse in the ER is caring for an Asian-American with an acute asthma attack. When assessing the client, the nurse understands that which of the following information holds the least priority? A. History of present illness B. Psychosocial assessment C. Neurological status D. Vital signs and oxygen saturation

Choice D is correct. The most common complication associated with thoracentesis is a pneumothorax. The nurse should assess the client for this adverse reaction which includes the client experiencing tachypnea, coughing, decreased or absent lung sounds on the affected side, and decreased blood oxygen levels.

The nurse is assessing a client immediately following a thoracentesis. The nurse understands that the most common complication following this procedure is a A. Pleural effusion B. Pneumonia C. Pulmonary embolism D. Pneumothorax

Choice C is correct. A pneumothorax has clinical features such as reduced breath sounds on the affected sides, tachypnea, dyspnea, and pleuritic chest pain. Some clients may be asymptomatic, depending on the size of the pneumothorax.

The nurse is assessing a client who has a pneumothorax. Which of the following assessment findings should the nurse expect? A. Blood-tinged sputum B. Increased anterior-posterior diameter C. Reduced breath sounds on the affected side D. Auscultation of a loud, rough, grating sound

Choice D is correct. A retinal detachment is a medical emergency as it may become progressive and give the client blindness in the affected eye. The client may experience a loss of vision that appears as if a curtain is closing, or they may experience bright flashes of light.

The nurse is assessing a client who has a suspected retinal detachment. Which of the following client statements would be consistent with this diagnosis? A. "My vision has a cloudy appearance." B. "I have intense pain above my eyebrow." C. "I am having trouble with my peripheral vision." D. "I can see bright flashes of light."

Choice A is correct. Diminished or absent breath sounds in the affected area are an expected finding with pneumothorax. This is because air has entered the pleural space and collapsed that portion of the lung making it ineffective in gas exchange.

The nurse is assessing a client who has sustained a blunt chest injury. Which of the following findings would support a diagnosis of pneumothorax? A. Diminished breath sounds B. Barrel chest C. Bradypnea D. Pulse deficit

Choice C is correct. Notifying the PHCP is essential because this assessment indicates crepitus which is air trapped in and under the skin, known as subcutaneous emphysema. The PHCP needs to be notified because this is a complication, and measures such as increasing the suction on the chest tube need to be considered.

The nurse is assessing a client with a chest tube for a pneumothorax. The nurse assesses a crackling sensation beneath the fingertips around the chest tube insertion site. The nurse should take which action? A. Document the finding as normal B. Clamp the chest tube C. Notify the primary healthcare provider (PHCP) D. Apply nasal cannula oxygen

Choice B is correct. The nurse may assess for crepitus by palpating the skin around the chest tube and observing for a crackling sensation. Crepitus is defined as infiltration of air in the subcutaneous layer of the skin, also known as subcutaneous emphysema. It is caused by air leaking into the subcutaneous space.

The nurse is assessing a client with a chest tube for crepitus. Which assessment technique is most appropriate for the nurse to perform? A. Press down on the client's abdomen, releasing, and assessing for pain. B. Palpate the skin around the chest tube and observe for a crackling sensation. C. Auscultating the bowel sounds in each quadrant. D. Inspect the client's chest for an even rise and fall.

Choice D is correct. CO poisoning is odorless, colorless, and tasteless. This potentially lethal poison initially causes clients to develop symptoms such as headache, reduced visual acuity, and slight breathlessness. As the CO level increases, it causes hypotension, confusion, and vertigo and then progresses to death.

The nurse is assessing a client with carbon monoxide (CO) poisoning. Which of the following would be an expected finding? A. Decreased pulse oximetry (SpO2) B. Hyperarousal C. Bradycardia D. Headache

Choice A is correct. The client has a fever, and the treatment for a fever includes fluids and antipyretics such as acetaminophen or ibuprofen. Fever increases the work of breathing and may cause respiratory muscle fatigue, precipitating an exacerbation of chronic obstructive pulmonary disease (COPD). Therefore, the fever should be controlled. The etiology of the fever in a COPD client should be identified (bronchitis, pneumonia) and treated.

The nurse is assessing a client with chronic obstructive pulmonary disease (COPD). Based on the vital signs, what action should the nurse take? See the image below. A. Administer acetaminophen (APAP) B. Provide the client with warm blankets C. Apply oxygen at 2 liters via nasal cannula D. Obtain an arterial blood gas (ABG)

Choice C is correct. Bronchovesicular sounds occur over major bronchi where there are fewer alveoli. They are moderate in pitch and amplitude and are normally equal during inspiration and expiration. Posteriorly, bronchovesicular breath sounds can be auscultated between the scapulae.

The nurse is auscultating bronchovesicular lung sounds on a client. The nurse understands that these lung sounds are best heard A. right second intercostal space. B. midclavicular line, in the fifth intercostal space. C. posteriorly, between the scapula. D. over the trachea.

Choice A is correct. It is necessary to hyper-oxygenate the client prior to taking any of the other actions. This is one of the first steps in suctioning a tracheostomy. The nurse hyper-oxygenates the client to prepare them for the procedure and prevent oxygen desaturation. The nurse then inserts the suction catheter without suctioning to the pre-measured depth, applies intermittent suction, and rotates the suction catheter while removing it from the tracheostomy.

The nurse is caring for a 10-year-old client with a tracheostomy tube. The nurse notices that the client has a large amount of secretions and prepares the client for suction. Which action should the nurse take first? A. Hyperoxygenate the client B. Ask the client to take a deep breath C. Place the client in the supine position D. Notify the charge nurse

Choice A is correct. Impaired mobility in older adults creates a risk for airway collapse, reduced air exchange, hypoxia, hypercapnia, and acidosis. Reduced gag and cough reflexes can place older people at risk for aspiration of secretions and, potentially, aspiration pneumonia. There is a possibility of postoperative respiratory complications because of impaired cough reflex, weaker muscles, and decreased inspiratory capacity. Older adults are at increased risk of respiratory complications due to stress. The nurse should pay attention to maintaining adequate ventilation, keeping lung volumes high, clearing secretions, and positioning to prevent aspiration.

The nurse is caring for a 76-year-old client with pneumonia. What is the priority nursing assessment A. Airway patency B. Percussion sounds C. Breath sounds D. Respiratory rate

Choice B is correct. Respiratory complications following rapid removal of fluid include hypoxemia and pulmonary edema. Assessing the client's respiratory status is a high priority and would be the first action the nurse should take.

The nurse is caring for a client following a bedside thoracentesis. Which action should the nurse take immediately following the procedure? A. Instruct the client to take slow, shallow breaths B. Assess the client's respiratory status C. Label the lab specimen for culture D. Call the radiology department to arrange for a postprocedure chest radiograph (x-ray)

Choice D is correct. The client states that they feel short of breath, indicating possible respiratory distress. A common complication of bronchoscopy is pneumothorax. The nurse should immediately assess the client for other pneumothorax symptoms (decreased breath sounds on the affected side, tachypnea, tachycardia) and initiate appropriate interventions.

The nurse is caring for a client following a bronchoscopy. Which assessment finding requires follow-up? A. The client coughs when having small sips of water B. The client complains of a sore throat C. The client expectorates green sputum D. The client complains that he cannot catch his breath

Choices A, B, C, and E are correct. Complications following a thoracentesis include pneumothorax, bleeding, and infection. The biggest concern is pneumothorax. Following a thoracentesis, the client should be assessed for increased respiratory rate, elevated heart rate, nagging cough, decreased oxygen saturation, decreased breath sounds, and air that makes a popping sound near the insertion site when palpated. These are complications and warrant an immediate chest radiograph and supportive measures.

The nurse is caring for a client immediately following an ultrasound-guided thoracentesis. Which client finding requires follow-up? Select all that apply. Nagging cough Trachea slanted more to the unaffected side Rapid heart rate Localized discomfort at the needle site Crackling sound made at the insertion site when palpated

Choice B is correct. Respiratory acidosis. The trick to interpreting ABGs is to know the normal values and to use a systematic process for interpretation. Normal values for ABGs are pH: 7.35-7.45, PaO2 = 75-100 mmHg, PaCO2 = 35-45 mmHg, HCO3 = 22-26 mEq/L, and O2 sat = 94-100%. First, look at the pH. In this case, the pH is < 7.35, which indicates an acidotic condition. Second, examine the PaCO2. In this case, the value is > 45 mmHg, which indicates this is respiratory acidosis.

The nurse is caring for a client in the emergency department. The client is short of breath upon arrival to the ED and is coughing up purulent sputum. Oxygen is being administered at 2 liters per minute via nasal cannula. The client's blood pressure is 100/58 mmHg, pulse is 88, and respiratory rate is 24. The client is afebrile with an oxygen saturation of 92%. The results of arterial blood gas testing are: pH = 7.25, PaO2 = 93, PaCO2 = 69, and HCO3 = 25. The nurse understands that this ABG shows: A. Respiratory alkalosis B. Respiratory acidosis C. Metabolic alkalosis D. Metabolic acidosis

Choice A is correct. The most immediate postoperative risk factor is pneumothorax. Thoracentesis is when a needle is inserted into the pleural space between the lungs and the chest wall. This procedure removes pleural effusion (excess fluid) from the pleural space to help ease breathing. The risks of this procedure may include air in the area between the lung covering (pleural space) that causes the lung to collapse (pneumothorax), bleeding, infection, and liver or spleen injury (rare). Symptoms of pneumothorax include dyspnea, chest pain, shortness of breath, and frequent coughing.

The nurse is caring for a client who had a thoracentesis two hours ago. Which assessment finding requires follow-up? A. persistent cough B. soreness at the needle site C. urine output of 200 mL D. scant bloody drainage

Choice A is correct. A retinal detachment is an ocular emergency. The client moving may hasten the detachment. It is important to inform the client to restrict their activity, and the nurse should apply an eye patch to the affected eye.

The nurse is caring for a client who has developed retinal detachment. Which of the following actions should the nurse take first? A. Instruct the client to restrict activity B. Establish a vascular access device C. Review the client's current medications D. Educate the client about topical eye ointments

Choice C is correct. Speaking at a normal volume is the preferred approach when communicating with a client with impaired hearing. It allows for clear and effective communication without the need for shouting or raising one's voice. This approach respects the client's dignity and promotes understanding.

The nurse is caring for a client who has impaired hearing, the nurse knows that the best way to approach them is to do which of the following? A. Speak loudly B. Speak quickly C. Speak at a normal volume D. Speak into the impaired ear

Choice A is correct. Timolol is an intraocular beta-blocker and is effective in treating angle-closure glaucoma. This medication is indicated for this ocular emergency as it lowers intraocular pressure.

The nurse is caring for a client with angle-closure glaucoma. Which prescription should the nurse anticipate from the primary healthcare provider (PHCP)? A. Timolol B. Hydroxyzine C. Phenylephrine D. Imipramine

Choice D is correct. For a client with a new tracheostomy, a concerning finding would be subcutaneous emphysema, which occurs when there is an opening or tear in the trachea and air escapes into the fresh tissue planes of the neck. Air can progress throughout the chest and other tissues into the face. The nurse may assess for subcutaneous emphysema by palpating the trachea.

The nurse is caring for a client who is one-day post-operative following a total laryngectomy with a tracheostomy placement. When providing tracheostomy care, which assessment finding requires immediate follow-up? A. bloody secretions B. edematous stoma C. soreness at the incision site D. subcutaneous emphysema

Choices B, C, and E are correct. The cardinal features of Meniere's disease include sensorineural hearing loss, vertigo, and tinnitus. These features relapse and remit and can be debilitating.

The nurse is caring for a client with Meniere's Disease. Which of the following assessment findings would be expected? Select all that apply. Presbyopia Tinnitus Vertigo Dyskinesia Hearing loss

Choice A is correct. Fluctuation in the water seal column of a chest tube drainage system typically indicates proper functioning of the system. Cessation of fluctuation may occur due to various reasons, but one common cause is the presence of fibrin clots in the tubing. Fibrin clots can obstruct the flow of air and fluid within the tubing, leading to the absence of fluctuation. This situation should be promptly assessed and addressed to ensure proper drainage and prevent complications. This may also occur when the lung becomes fully expanded.

The nurse is caring for a client with a chest tube drainage system. The nurse notes that the fluid in the water seal column is not fluctuating. The nurse knows that the best explanation of fluctuation cessation is that: A. There may be fibrin clots in the tubing B. The lung is collapsing C. There has been an increase in intrapleural pressure D. The tubing may have become dislodged from the chest

Choice C is correct. The chest tube is usually connected to an underwater seal system. The underwater seal system restores appropriate pressure to the lungs, facilitates the air to exit from the pleural space on exhalation, and prevents it from reentering the pleural cavity during inhalation. A chest tube disconnected from the underwater seal system is a medical emergency. A bottle of sterile water is essential to have at the bedside because if the chest tube becomes disconnected from the chest tube system, the nurse can maintain the patency of the system by putting the end of the tube in sterile water, which will prevent air from reentering the pleural space.

The nurse is caring for a client with a chest tube for the treatment of a pneumothorax. Which item is essential to have at the bedside? A. Nasal cannula oxygen B. Tracheostomy set C. Bottle of sterile water D. An ampule of Dextrose 50%

Choice A is correct. The initial nursing priorities for a hyphema are shielding the affected eye and raising the head-of-the bed to 30 degrees.

The nurse is caring for a client with a hyphema. The nurse should plan to take which action? A. Shield the affected eye. B. Place the client supine. C. Apply a cold compress to the eye. D. Request a prescription for aspirin.

Choice B is correct. Restlessness is an ominous sign suggestive of hypoxia. Hypoxia indicates pulmonary embolism (PE) that is advancing, and the client is becoming unstable. The nurse should immediately follow up on this finding.

The nurse is caring for a client with a pulmonary embolism (PE). Which of the following findings require immediate follow-up? A. Pleuritic chest pain B. Restlessness C. Cough D. Exertional dyspnea

Choice B is correct. The nurse needs to obtain vital signs because a client with a suspected pulmonary embolism may experience hypoxia, tachypnea, and tachycardia. The nurse can intervene by providing supplemental oxygen if the vital signs show hypoxia. Finally, the nurse will need to notify the physician, and having recent vital signs is essential to determine the client's overall stability. Choice D is correct. The client should be placed in a high Fowler's position. This allows full chest expansion, which may optimize the client's oxygen saturation.

The nurse is caring for a client with a suspected pulmonary embolism. After the nurse notifies the rapid response team, the nurse should perform which action? Select all that apply. place the client in a left lateral trendelenburg position obtain vital signs obtain a prescription for warfarin place the client in the high-Fowler's position obtain an order for a chest radiograph (x-ray)

Choices B and D are correct. When caring for a client with a tracheostomy, suctioning should be performed only when clinically indicated. Indications for suctioning the client include tachypnea, rhonchi in the lung fields, and decreasing oxygen saturation. When suctioning a tracheostomy, the nurse should use a sterile technique, and a maximum of three passes should be completed. The oxygen must be warm and humidified for a client receiving oxygen via a trach collar. If it is not appropriately warmed or humidified, tracheal damage may occur. The humification assists with the passage of the secretions.

The nurse is caring for a client with a tracheostomy receiving oxygen via tracheostomy collar. The nurse should plan to Select all that apply. Plan to suction the tracheostomy every two to four hours Ensure that the oxygen is humidified Instill normal saline down the tracheostomy immediately before suctioning Suction the tracheostomy for a maximum of three passes Apply suction as the catheter is inserted into the tracheostomy

Choice B is correct. The client with acute angle-closure glaucoma should be placed supine, which will assist in the lens falling away from the iris, mechanically helping to relieve angle closure and decreasing the pupillary block. Clients with open-angle glaucoma (OAG) are advised to sleep with their heads elevated to about 30 degrees. However, there is insufficient evidence to recommend the same for angle closure glaucoma. The supine position is widely accepted for angle-closure glaucoma.

The nurse is caring for a client with acute angle-closure glaucoma of the right eye. It would be correct to place the client in which position? A. Trendelenburg B. Supine C. Right lateral decubitus with head end elevated D. Prone

Choice A is correct. Acetazolamide is a diuretic given intravenously or orally to a client with angle-closure glaucoma. Angle-closure glaucoma is a medical emergency that may cause blindness if not promptly treated. Acetazolamide causes a reduction in aqueous humor production by directly inhibiting carbonic anhydrase. As a result, it helps treat angle-closure glaucoma with intraocular pressure (IOP) greater than 30 mmHg. Acetazolamide acts within one hour of administration, and its therapeutic effects peak within four hours.

The nurse is caring for a client with angle-closure glaucoma. Which prescription should the nurse anticipate from the primary healthcare provider (PHCP)? A. Acetazolamide B. Diphenhydramine C. Phenylephrine D. Nortriptyline

Choice B is correct. Polycythemia is a condition with increased red blood cells in the blood. Low blood oxygen levels, a clinical feature associated with COPD, cause the kidneys to respond by releasing erythropoietin (EPO), which stimulates red blood cell production. The red blood cell count is elevated to compensate for hypoxia or low oxygen levels. More cells are available to carry and deliver the maximum amount of oxygen.

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) with a chronically increased red blood cell count (RBC). The nurse understands that this finding is likely from A. Increased carbon dioxide levels B. Low blood oxygen levels C. Insensible water loss D. Decreased fluid intake

Choice D is correct. A closed chest drainage system is the priority postoperative intervention for a client who has had a left lower lobe removal. This system is used to manage the drainage of air or fluid from the pleural space, which is crucial in preventing complications such as pneumothorax or pleural effusion.

The nurse is caring for a client with lung cancer who recently had a left lower lobe removal. Which postoperative intervention will be performed as a priority in the care of this client? A. Tracheostomy B. Mediastinal tube C. Incentive spirometer D. Closed chest drainage system

Choice A is correct. This client demonstrates signs of acute respiratory distress syndrome (ARDS), a complication of pneumonia (hypoxemia). The client's inability to oxygen is highly concerning and is a classic manifestation of ARDS. An RRT should be immediately called to assist with appropriate interventions, including intubation by a qualified provider.

The nurse is caring for a client with pneumonia receiving six liters a minute of nasal cannula oxygen. The client has a SpO2 of 81%, and the arterial blood gas (ABG) returns with a PaO2 of 68 mm Hg. Which immediate intervention should the nurse take? A. Notify the rapid response team (RRT). B. Obtain a prescription for a chest radiograph. C. Increase nasal cannula oxygen to seven liters a minute. D. Auscultate the lung fields for adventitious sounds.

Choice D is correct. The dislodgment of a chest tube is considered an emergency. The nurse's initial intervention should be to immediately apply an occlusive dressing to the site when the client exhales. The nurse should tape it on three sides to prevent a tension pneumothorax. Once a dressing is in place, the nurse should send a colleague to notify the health care provider (HCP) immediately while remaining with the client and closely monitoring the client's vital signs and respiratory status.

The nurse is caring for a client with pneumothorax with a chest drainage system in place. On assessment, the system has become dislodged from the client. The nurse should initially A. obtain an order for chest radiograph (x-ray) B. prepare the client for intubation via an endotracheal tube (ETT). C. notify the primary healthcare provider. D. place an occlusive dressing over the site and tape on three sides.

Choice C is correct. The vital signs (VS) show an increased pulse (123 bpm) and elevated blood pressure. Albuterol is a beta-receptor agonist and would foreseeably worsen the tachycardia that the client is already experiencing. The nurse should clarify the albuterol prescription with the primary health care provider (PHCP) because albuterol may increase heart rate.

The nurse is caring for a client with the following clinical data, as shown in the exhibit. Which medication would the nurse be concerned about before administration based on the vital signs? See the exhibit. View Exhibit A. Metoprolol 50 mg PO Daily B. Lisinopril 40 mg PO Daily C. Albuterol 2.5 mg via nebulizer Daily D. Diltiazem XR 120 mg PO Daily

Choice B is correct. This patient would be the safest sleeping on their right side. This helps prevent edema in the operative eye. This patient would also benefit from being placed in semi-Fowler's position.

The nurse is caring for a patient who had a cataract removal from their left eye a few hours ago. Which statement if made by the patient's wife indicates an understanding of the post-operative care instructions? A. "He should sleep on his left side." B. "He should sleep on his right side." C. "He should lay on his stomach to promote draining." D. "He needs to sleep sitting completely upright."

Choice B is correct. Ringing in the ears or tinnitus is the most common complaint from people with inner ear disorders.

The nurse is caring for a patient with a disorder of the inner ear. Which of the following is the most common complaint about patients with these disorders? A. Itchiness B. Ringing in the ears C. Hearing loss D. A burning sensation in the ear

Choice B is correct. Following a thoracentesis, the nurse must assess the client for the most common complication of pneumothorax. Manifestations of a pneumothorax that are concerning include a nagging persistent cough, increased heart and respiratory rate, dyspnea, and potentially a feeling of air hunger. The nurse must act quickly because the client's condition may deteriorate. Depending on the size of the pneumothorax, a chest tube may be needed.

The nurse is caring for assigned clients. The nurse should immediately follow up with the client who A. has influenza and their most recent temperature was 102°F (39°C). B. is recovering from a thoracentesis and reports a nagging cough. C. reports reddish-brown sputum immediately following a bronchoscopy. D. has pulmonary tuberculosis and is wearing a surgical mask while ambulating to radiology.

Choice A is correct. It is essential that a client receiving oxygen therapy have smoke detectors and a fire extinguisher as oxygen therapy enhances combustion. Having functional smoke detectors and a fire extinguisher is a priority because it promotes client safety.

The nurse is completing a home assessment for a client receiving oxygen therapy. Which essential piece of equipment should be available? A. Smoke detector B. Extension tubing C. Slip-resistant rugs D. Air humidifier

Choices A, B, and C are correct. According to the Centers for Disease Control (CDC), risk factors for TB include immunosuppression, organ transplant, chronic corticosteroid use, substance use, diabetes mellitus, and residing in environments such as nursing homes, prisons, and homeless shelters.

The nurse is conducting a health screening at a local health fair. Which of the following should the nurse recognize as a risk factor for developing pulmonary tuberculosis (TB)? Select all that apply. Human Immunodeficiency Virus (HIV) Organ transplant Chronic corticosteroid use Influenza vaccination Obesity

Choices B, C, and D are correct. Risk factors for primary open-angle glaucoma (POAG) include hypertension, African American ethnicity, family history, diabetes mellitus, and any condition that may cause an increase in intraocular pressure. Hypertension increases IOP. Because African Americans are at higher risk for developing hypertension, they are impacted by the condition's negative vascular impacts. Diabetes, especially if uncontrolled, may cause vascular damage, and the eyes are commonly affected. Annual eye examinations for a client with diabetes are recommended.

The nurse is conducting a health screening at a local health fair. Which of the following should the nurse recognize as an increased risk for developing primary open-angle glaucoma? Select all that apply. Blue eyes Older age African ethnicity Diabetes mellitus Use of contact lenses

Choices A, B., D, and E are correct. A is correct. Adequate lighting is necessary for the client to see the nurse's facial expressions and lip movements, which can help them understand what the nurse is saying. B is correct. Non-verbal communication can be beneficial for clients with hearing impairments. Using gestures and sign language can aid in the communication process. D is correct. When speaking to the client, the nurse should face them directly. This allows the client to use lip reading and visual cues to understand the conversation better. E is correct. Providing written information can be beneficial for clients with hearing impairments, especially for complex or essential information. This ensures that the client has all the information needed, even if some verbal communication is not understood.

The nurse is developing a care plan for a client with a hearing impairment. Which of the following interventions should the nurse take? Select all that apply. Ensure that the room is well lit when communicating with the client. Use non-verbal forms of communication like gestures and sign language, if applicable. Speak loudly and shout when communicating with the client. Face the client directly when speaking. Provide written information as needed.

Choices A, B, D, and E are correct. Post-procedure, the client should be taught how to instill eye drops. If not the client, then a family member or friend. The client should not lie on the operative side, and an eye patch may be given to protect the eye from injury while they are sleeping. Any activities such as bending at the waist, coughing, or vomiting should be avoided as they raise the intraocular pressure.

The nurse is developing a discharge plan for a client who had a phacoemulsification procedure. Which of the following should the nurse include? Select all that apply. Teach the client how to instill eye drops. Instruct the client not to lie on the affected side. Remind the client that a reduction of vision is normal. Provide the client with an eye patch for the affected eye. Educate the client to avoid bending at the waist.

Choice B is correct. Initiating vascular access is essential for a client admitted with P. aeruginosa pneumonia because parenteral antibiotics are the mainstay of treatment. Dehydration is common in pneumonia, and encouraging non-caffeinated fluids is beneficial.

The nurse is developing a plan of care for a client admitted P. aeruginosapneumonia. Which of the following should the nurse include in the client's plan of care? A. Instruct the client to wear an N95 mask when ambulating in the hall. B. Initiate a vascular access device and encourage by-mouth fluids. C. Obtain daily weights every morning using the same scale. D. Administer prescribed oseltamivir within 48 hours of symptom onset.

Choices D and E are correct. Ambulation with a chest tube is not contraindicated. If the nurse has an order from the primary healthcare provider (PHCP) and it is safe for the client to ambulate, the nurse should ambulate the client with the device distal to the insertion site. Palpating around the insertion site should be done and any crackles or popping should be reported to the PHCP because that indicates an air leak.

The nurse is developing a plan of care for a client with a wet-suction chest tube prescribed wall suction. Which interventions would be appropriate to include? Select all that apply. Apply clamps to the tubing to secure it to the bed. Strip the tubing at least once every eight hours. Report any bubbling in the suction control chamber. Ambulate the client with the device below the insertion site. Palpate around the insertion site for any crackles or popping.

Choice A is correct. Bronchodilators, such as inhalers, can impact the results of pulmonary function tests. It is generally recommended to withhold the use of a bronchodilator for a specific period before the tests to obtain accurate results. This period may vary depending on the specific medication and the healthcare provider's instructions, but the client's statement about withholding the bronchodilator for four to six hours before the tests is generally appropriate.

The nurse is educating a client scheduled for pulmonary function tests. It would indicate effective teaching if the client makes which statement? A. "I should not use my bronchodilator four to six hours before these tests." B. "I should not eat or drink six to eight hours prior to these tests." C. "I will need someone to drive me home after I wake up from the anesthesia." D. "My gag reflex will have to return before I resume eating and drinking."

Choice C is correct. Placing a sterile occlusive dressing taped on three sides over the chest tube site and calling for help would be the priority actions. The nurse follows infection prevention by placing a sterile dressing over the site. Taping the dressing on three sides will cover the site. The open side will prevent a tension pneumothorax by allowing exhaled air to escape the dressing. The nurse should then immediately call for help.

The nurse is helping a client with a chest tube ambulate to the bathroom. The client turns suddenly and the chest tube becomes dislodged. What is the priority action for the nurse to take? A. Immediately re-insert the tube and call for help. B. Place your ungloved hand over the chest tube site and yell for help. C. Place a sterile dressing taped on three sides over the chest tube site and call for help. D. Monitor the patient's vital signs while he finishes ambulating to the bathroom and then call for help.

Choice C is correct. Tactile (vocal) fremitus describes the vibrations that can be palpated through the chest wall during speech. To assess tactile fremitus, the nurse would place hands over the lung apices in the supraclavicular areas and palpate from one side to the other while the client repeats "ninety-nine" to compare vibrations. If vibrations are uneven, it may indicate pneumothorax, inflamed lung tissue, or fluid build-up.

The nurse is performing a physical assessment on an adult client. The nurse should assess for tactile fremitus by A. placing the thumbs on the client's spine at the level of the ninth ribs. B. asking the client to breathe slowly and deeply through an open mouth while auscultating lung sounds. C. asking the client to say "ninety-nine" while palpating the intercoastal spaces beginning at the lung apex. D. tapping the chest over the distal interphalangeal joint with the middle finger of the opposite hand.

Choice A is correct. Having a client stand 20 feet away from a Snellen chart is an appropriate assessment tool to determine a client's visual acuity. Snellen chart can be used to diagnose myopia ( near-sightedness) and hyperopia ( far-sightedness). While using a Snellen chart, the normal vision at a distance is set at 20/20. The numerator represents the distance that the patient is away from the chart ( in feet). The denominator represents the distance at which a person with normal vision can clearly read the smallest font that the patient perfectly sees at 20 feet.

The nurse is performing a physical assessment. The nurse should assess the client's visual acuity by obtaining which of the following? A. Snellen chart B. Tonometer device C. Penlight D. Slit lamp

Choice B is correct. Cheyne-Stokes respiration is characterized by apnea alternating with periods of rapid breathing. This pattern is often seen in various medical conditions, including heart failure and brain injuries.

The nurse is performing a respiratory assessment of a client with abnormal breathing patterns. The client has periods of apnea with periods of gradually increasing and decreasing breaths. How should the nurse chart this breathing style? A. Neurogenic hyperventilation B. Cheyne-Stokes C. Apneustic D. Ataxic

The nurse is precepting a graduate nurse caring for a client with a chest tube. Which of the following statements made by the graduate nurse would indicate an expected finding? Select all that apply. "The drainage system was below the insertion site." "Vigorous bubbling was in the water-seal chamber." "The client reported pain at the insertion site." "An occlusive dressing was over the chest tube." "The chest tube was clamped for ten minutes to determine if a leak was present."

The nurse is precepting a graduate nurse caring for a client with a chest tube. Which of the following statements made by the graduate nurse would indicate an expected finding? Select all that apply. "The drainage system was below the insertion site." "Vigorous bubbling was in the water-seal chamber." "The client reported pain at the insertion site." "An occlusive dressing was over the chest tube." "The chest tube was clamped for ten minutes to determine if a leak was present."

Choice B is correct. A total laryngectomy is the removal of the larynx and surrounding lymph nodes. This is a significant procedure that requires the placement of a tracheostomy. The client will need an interdisciplinary approach to their care. A central figure for a client with a tracheostomy is a respiratory therapist collaborating with the nurse regarding tracheostomy management.

The nurse is preparing a client for a total laryngectomy. When developing a plan of care for this client, the nurse recommends a consultation from which healthcare provider (HCP)? A. Endocrinology B. Respiratory therapy C. Dermatology D. Infectious disease

Choices A and B are correct. The physician will remove the chest tube device and is done after the sutures are removed. The chest tube is sutured into place to prevent tube migration. Having a suture removal kit readily available is an essential part of the chest tube discontinuation process. Removing a chest tube is painful, and administering prescribed pain medication before removal will alleviate the discomfort.

The nurse is preparing for a physician to remove a client's chest tube used to treat a hemothorax. Which actions should the nurse perform before removing the tube and drainage system? Select all that apply. Placing a suture removal kit at the bedside Administering prescribed pain medication Clamping the chest tube for 30 minutes prior to removal Obtain a trash bag to dispose of the system Obtain a prescription for a intravenous bolus of isotonic saline

Identify the client, perform hand hygiene, and gather supplies Apply a continuous pulse oximeter to the client Perform hand hygiene and apply personal protective equipment (PPE) Using an aseptic technique, open the suction kit or catheter package and prepare supplies Apply sterile gloves Place the tip of catheter into a sterile basin and suction a small amount of normal saline solution from the basin by occluding the suction vent Suction the client as the catheter is removed for a maximum of 15 seconds.

The nurse is preparing to suction a client's tracheostomy. Place the steps in the appropriate order that the nurse should perform. Place the steps below in the appropriate order. Press and hold an option to rearrange Perform hand hygiene and apply personal protective equipment (PPE) Apply a continuous pulse oximeter to the client Apply sterile gloves Using an aseptic technique, open the suction kit or catheter package and prepare supplies Suction the client as the catheter is removed for a maximum of 15 seconds. Identify the client, perform hand hygiene, and gather supplies Place the tip of catheter into a sterile basin and suction a small amount of normal saline solution from the basin by occluding the suction vent

Choices A, B, and C are correct. A pulse oximetry device should be provided to the client, and they should be encouraged to log their oxygen saturations as directed. If the client experiences dyspnea or tachypnea, the client should be instructed to seek medical attention for a level less than 95% (unless otherwise directed). Padding the tubing around pressure ears (back of the ears) is recommended to avoid injury. A sign posted on the door should be visible to alert visitors of the oxygen and extinguish and open flames.

The nurse is providing discharge instructions to a client prescribed nasal cannula oxygen. Which of the following instructions should the nurse include? Select all that apply. Keep a pulse oximetry device readily available. Pad the tubing in areas that put pressure on the skin. Have a sign on your door indicating the presence of oxygen. Use the oven and not the stovetop to cook. You may apply petroleum jelly to your nares to prevent drying.

Choice A is correct. This statement indicates effective teaching by the nurse. Following cataract surgery, the client should not get water in the affected eye for three to seven days. This measure will reduce the potential for infection.

The nurse is providing discharge instructions to a client who underwent left eye cataract surgery with a lens implant. Which statement by the client would indicate a correct understanding of the teaching? A. "I should avoid getting water in the eye for 3 to 7 days after surgery." B. "It is okay for me to resume normal chores such as vacuuming." C. "It is okay for me to have green or yellow, thick drainage from the eye." D. "I may take aspirin for any pain I may experience."

Choice D is correct. A shower shield should be placed over the tracheostomy when the client bathes. This would prevent water from entering the tracheostomy and potentially lead to pneumonia.

The nurse is providing discharge instructions to a client with a tracheostomy. Which of the following instructions should the nurse include? A. You may use lemon glycerin swabs for mouth care. B. Remove the old tracheostomy ties before applying the new ties. C. You may use warm tap water to clean the inner cannula. D. Wear a shower shield over the tracheostomy when bathing.

Choice D is correct. An elevated temperature indicates some form of infection. In a client with COPD, the common infections include bronchitis or pneumonia. Any respiratory infection may cause an exacerbation of COPD. A client who did not receive pneumonia or influenza vaccines is at increased risk of developing pneumonia and influenza. Monitoring for signs/symptoms of infection is a crucial nursing intervention. Fever increases respiratory workload and may precipitate a flare-up of COPD. Fever should be controlled, and the underlying etiology should be identified and treated promptly. The nurse should educate the client to receive the annual influenza vaccine and stay current on their pneumonia vaccine.

The nurse is reviewing vital signs for a client admitted with abdominal pain and has a medical history of chronic obstructive pulmonary disease (COPD). Which vital sign requires follow-up by the nurse? A. Blood pressure 130/70 mm Hg B. Respiratory rate 24 breaths/min C. Pulse oximetry 91% on room air D. Oral temperature of 101.1° F (38.4° C)

Choice A is correct. It is appropriate for the nurse to finish counting the client's respirations and continue to monitor them as normal. Fluctuations of water in the water-seal chamber with inspiration and expiration are a sign that the drainage system is patent. Normally, the water level will increase when the client breathes in, and then decrease when they breathe out. This is due to changes in intrathoracic pressures.

The nurse is taking vital signs for a client who has a chest tube in place. While counting the client's respirations, the nurse notes that the water in the water-seal-chamber is fluctuating. Which action by the nurse is most appropriate based on this finding? A. Finish counting the client's respirations B. Empty the water-seal chamber C. Assist the client with incentive spirometry D. Notify the charge nurse

Choice C is correct. The most significant risk factor for COPD is cigarette smoking. Cigarette smoking causes airway obstruction via the destruction of elastin and collagen, contributing to the development of COPD. The nurse should remind community members that several prescribed medications are available to cease cigarette smoking. Treatments include bupropion, varenicline, and nicotine replacement therapy.

The nurse is teaching a health promotion class to a group of community members on preventing chronic obstructive pulmonary disease (COPD). The nurse should emphasize that a significant risk factor for COPD is A. environmental pollution. B. endobronchial infections. C. cigarette smoking. D. reactive airway disease.

Choices B and D are correct. These two statements should be included in patient education about thoracentesis. A thoracentesis is a procedure indicated for pleural effusions. The client will need to report any dyspnea after the procedure (Choice B). Shortness of breath following the thoracentesis procedure may indicate either iatrogenic pneumothorax or re-expansion pulmonary edema. Pneumothorax is a common complication following thoracentesis (studies report post-thoracentesispneumothorax rates ranging from 0 to 19%). The nurse should assess the client carefully for any signs of pneumothorax. Symptoms and signs of a pneumothorax include shortness of breath and reduced or absent breath sounds on the affected side. A more severe pneumothorax, such as tension pneumothorax, may present with obstructive shock. A nurse must notify the physician immediately if any of such signs/symptoms were to occur. A chest x-ray (Choice D) must be completed post-procedure to make sure there is no iatrogenic pneumothorax even if the patient did not show any of the above signs or symptoms. Re-expansion pulmonary edema (REPE) is a complication that occurs after rapid re-expansion of a collapsed lung within 1 to

The nurse is teaching a patient who is scheduled for a thoracentesis. Which of the following information should the nurse include? Select all that apply. "This procedure will require you to receive general anesthesia." "You will need to report any shortness of breath following the procedure." "You will need to empty your bladder before this procedure." "After the procedure, a follow-up chest x-ray will be done." "You will need to be on a clear liquid diet one day before the procedure."

Choice A is correct. Cheyne-Stokes respirations are characterized when the respiratory rate and depth are irregular and alternate with periods of apnea and hyperventilation. The pattern then reverses, and the breathing slows and becomes shallow, concluding as apnea before respiration resumes. This may occur in older adults without any underlying pathology. This also could be characteristic of the client's critical condition following a neurological injury.

The nurse performs a respiratory assessment on an older adult client and observes apnea alternates with periods of rapid breathing. The nurse should document this respiratory pattern as A. Cheyne-Stokes. B. Kussmaul's. C. agonal. D. tachypnea.

Choices C, D, and E are correct. Sharing towels should be discouraged to prevent the spread of infection to other family members. Rubbing the eyes can cause injuries to the eye itself and cause the other eye to become infected. Further, the client should not share linens with others as this may cause disease transmission.

The nurse provides discharge instructions to a client diagnosed with bacterial conjunctivitis. Which of the following statements by the client would indicate effective understanding? Select all that apply. "It is okay for me to wear my contact lenses during this infection." "Swimming during this infection is allowed." "I should not share my towels with family members." "To prevent injury, I should not rub my eye." "I should wash my hands frequently."

Oxygen saturation

The nurse re-assesses and updates the nurse's note after administering the nasal cannula oxygen and albuterol via nebulizer Based on the nursing note (2), which finding from the 1555 entry indicates that the client requires further intervention? Reports of nervousness Respiratory rate Pulse rate Oxygen saturation

Choice A is correct. The client's ABG indicates hypoxemia. The normal PaO2 is 80-100; therefore, the nurse should give oxygen to address the situation.

The nurse reviews a client's arterial blood gas results. Based on the results, the nurse plans to obtain a physician's order to See the image below. A. administer supplemental oxygen. B. instruct the client to take deep breaths. C. administer sodium bicarbonate intravenously. D. reassess the ABG in two hours.

Choice D is correct. Presbycusis is a type of sensorineural hearing loss associated with aging. Sensorineural hearing loss is often permanent. Interventions for a client with this type of hearing loss include speaking in the ear less affected, speak clearly and slowly, avoid shouting, and ensure that the environment is well lit while conversing.

The nurse reviews a client's medical history and identifies a diagnosis of presbycusis. The nurse should integrate which intervention in the care plan? A. Have educational materials in large print B. Provide an eye patch to the affected eye C. Request food be seasoned with herbs D. Move closer to the better-hearing ear

airway narrowing; bronchodilator

The nurse should recognize that the expiratory wheezes indicate ______ The nurse understands that if oxygen and a ______ is not given the client's condition may worsen.

Choice D is correct. To prevent the intraocular pressure (IOP) from increasing, the client should be advised to remain seated, as the lying position may increase IOP and cause the glass to advance further into the eye. The nurse should also recommend the client rest and avoid unnecessary movement until a specialist (typically an ophthalmologist on call) arrives to evaluate the client.

The occupational health nurse was called to see a client who sustained injuries from a light bulb explosion. On assessment, the nurse notes that a piece of glass was lodged in the client's eye. The initial nursing intervention should be which of the following? A. Attempt to carefully remove the glass from the eye B. Reassure the client that everything is okay C. Administer a sedative for pain relief D. Advise the client to remain in a sitting position until a specialist arrives

Choice D is correct. Intense pain is not generally associated with retinal detachment. Retinal detachment may present with floaters in the field of visions, partial loss of sight, and increasingly blurred images. Some patients report feeling as though a curtain has been drawn over their eyes.

The patient has been experiencing inflammation of the eye and maybe experiencing a retinal detachment. Which of the following signs and symptoms are NOT associated with retinal detachment? A. Seeing "floaters" in the field of vision B. A sense of having a curtain drawn over the eyes C. Flashes of light D. Intense pain in the affected eye

Choice A is correct. The removal of a chest tube (CT) is a painful experience for the client and to promote comfort, the nurse should administer prescribed pain medication.

The primary healthcare provider (PHCP) plans for a chest tube to be discontinued. Prior to the PHCP removing the chest tube, the nurse should take which action? A. Administer prescribed pain medication B. Apply nasal cannula oxygen at 4 liters per minute C. Clamp the chest tube two hours before the removal D. Instruct the client to empty their bladder

Choice A is correct. If the PHCP prescribes a chest tube to be discontinued, nursing should have pertinent supplies such as a suture removal kit, occlusive gauze, dry sterile gauze, tape, biohazard bag and a clamp. A suture removal kit is necessary because the chest tube is sutured into place.

The primary healthcare provider (PHCP) prescribes the client's chest tube discontinuation. The nurse should place which supply item at the bedside for this procedure? A. Suture removal kit B. Bag valve mask (BVM) C. Nasal cannula oxygen D. Wall suction with tubing

apply supplemental oxygen; respiratory therapy; administration of albuterol via nebulizer

The priority for the nurse is to ______ To optimize this client's outcome, the nurse plans to collaborate with ____ It would be appropriate for the nurse to delegate the ____ to the licensed practical/vocational nurse (LPN/VN).

Choice B is correct. The sense of hearing is assessed using the Rinne test, Weber test, and a tuning fork.

The sense of hearing is assessed using which standardized test? A. Taylor test B. Rinne test C. Babinski test D. APGAR test

Choice A is correct. The cylinder must always be checked before use to ensure that enough oxygen is available for the patient.

What action does the nurse perform to follow safe technique when using a portable oxygen cylinder? A. Check the amount of oxygen in the cylinder before using it. B. Use a cylinder for a patient transfer that indicates available oxygen is at 500 psi. C. Place the oxygen cylinder on the stretcher next to the patient. D. Discontinue oxygen flow by turning the cylinder key counter-clockwise until it is tight.

Choices A, B, D, and E are correct. Incomplete lung expansion or the collapse of alveoli, known as atelectasis, prevents pressure changes and gas exchange by diffusion in the lungs. With atelectasis, lung tissue has collapsed, which leads to less lung mass available for oxygenation. The oxygen saturation is decreased, as well as breath sounds. Additionally, the patient will experience shortness of breath. Since alveoli collapse, there is more open space between the lung tissue and the chest wall. Open space does not transmit sound very well (decreased tactile fremitus). Areas of the lung with atelectasis cannot fulfill the function of respiration. Coughing, chest pain, cyanosis, dyspnea, and tachycardia are common symptoms of atelectasis.

What findings are expected when assessing a patient with atelectasis? Select all that apply. Decreased breath sounds Decreased tactile fremitus Hyperresonance Shortness of breath Decreased oxygen saturation

Choice B is correct. Ptosis is drooping of the eyelid.

When a patient presents with complaints of drooping of the eyelid on one side, the finding is documented as: A. Pharyngitis B. Ptosis C. Kernig sign D. Thyroglossal cyst

Choice A is correct. Normal documentation of the assessment of the nose would include findings such as symmetrical, midline, without drainage, and proportional to facial features.

When assessing a client's nose, the normal expected findings should be documented as: A. Nose symmetrical and midline B. Nose symmetrical with yellow drainage C. Nose asymmetrical with clear drainage D. Nose asymmetrical and proportional to facial features

Oxygen saturation 86% Absent breath sounds Respiratory rate 25 Left-sided chest pain

Which four (4) client findings indicate that the client is experiencing a pneumothorax? Oxygen saturation 86% Absent breath sounds Respiratory rate 25 Nasal Trauma Pulse 90 Disorientation Left-sided chest pain

Choice C is correct. This represents what a patient with macular degeneration would see. Their peripheral vision remains intact, while the central area becomes darker and darker until there is a spot in the center of their visual field through which they cannot see.

Which of the following images represent the visual field of a patient with macular degeneration?

Choices A and D are correct. Teaching points for exercising in patients with COPD include avoiding sudden position changes that may cause dizziness and avoiding extreme temperatures.

Which of the following should be included when teaching a 65-year-old male client with COPD about exercise? Select all that apply. Instruct the client to avoid sudden position changes that may cause dizziness. Recommend that the client restrict fluid until after exercising is finished. Instruct the client to push a little further beyond his fatigue with each session. Instruct the client to avoid exercising in very cold or very hot temperatures. Encourage the client to exercise if he feels ill or weak. Recommend to consume a high-carb, low protein diet.

Oxygen saturation Respiratory rate Lung sounds

Which of the following three (3) assessment findings would require immediate follow-up? Blood pressure Capillary refill Glasgow Coma Scale Oxygen saturation Medical history Respiratory rate Lung sounds

d-dimer level Chest computed tomography (CT) scan

Which orders does the nurse anticipate from the primary healthcare provider (PHCP)? Select all that apply chest physiotherapy pulmonary function tests purified protein derivative (PPD) skin test d-dimer level albuterol via nebulizer Chest computed tomography (CT) scan

Pneumonia

Which problem is the client most likely experiencing? Asthma Pneumonia Pleural effusion Septic shock

Choices A, B, C, D and E are correct. Atelectasis is defined as the total or partial collapse of the alveoli. This is a common complication in the immediate postoperative period, especially after abdominal surgeries. If atelectasis is not addressed, it may progress to pneumonia. Since alveoli are responsible for gas exchange, alveolar collapse can lead to impaired gas exchange/impaired oxygenation. Post-operatively, the client may not be able to take deep breaths due to pain from the movement of abdominal muscles. This impaired expansion of the alveoli leads to the accumulation of secretions/mucus plug, decreased surfactant, as well as the obstruction of airway and collapse of alveoli. Additional factors that predispose to this may include hypoventilation, sedation, and reduced mobility. When such factors are identified, the nurse should encourage the client to adopt interventions to mitigate those factors and prevent atelectasis. Such interventions include: Encouraging clients to take deep inspirations (Choice A) and use incentive spirometry (Choice E). An incentive spirometer encourages the client to pursue deep breathing. Deep breathing aids in gas exchange and promotes the full expan

You are assigned to take care of a client who just underwent a cholecystectomy. Which of the following would decrease the risk of developing atelectasis in this client? Select all that apply. Deep inspiration. Supine position with the head end of the bed elevated. Change position every 2 hours. Encourage the patient to cough at least 10 times/hr. Encourage use of incentive spirometry

Choice B is correct.This ABG shows a respiratory acidosis. The first clue in this patient is the diagnosis of COPD. In COPD, the patient suffers from severe hypoventilation. This hypoventilation results in the retention of carbon dioxide. The registered nurse must know the basics of ABG interpretation, including the normal ranges for each value. First, the nurse should look at the pH. The normal range is 7.35-7.45. A value below 7.35 indicates an acidosis; a value above 7.45 indicates an alkalosis. The normal partial pressure of carbon dioxide (PaCO2) is 35-45 mmHg. Standard bicarbonate for a man this age is 22-29 mmol/L. The pH in this patient shows that the condition is acidosis. The high PaCO2 indicates that it is a respiratory problem. These values would support the assumption based on the diagnosis of COPD. The pH and PaCO2 define respiratory disorders. Respiratory acidosis is defined as a pH below 7.35 and a PaCO2 above 45 mmHg. Respiratory alkalosis is defined as a pH above 7.45 and a PaCO2 below 35 mmHg. Metabolic disorders are defined by the pH and the bicarbonate (HCO3). Metabolic acidosis is defined as a pH below 7.35 and an HCO3 below 22 mmol/L. Metabolic alkalosis is defined

You are caring for a 55-year-old male patient in the emergency department. He has a history of chronic obstructive pulmonary disease (COPD). He came to the ED with a complaint of shortness of breath. His respiratory rate is 28 per minute, and his breaths are shallow and somewhat difficult. You put him on supplemental oxygen at 2 L/minute. You draw ABGs. You receive results of the arterial blood gas that show: pH = 7.30 PaCO2 = 49 Bicarbonate = 25 You determine that this ABG shows: A. Metabolic alkalosis B. Respiratory acidosis C. Respiratory alkalosis D. Metabolic acidosis

Choice B is correct. You should immediately stop the urokinase and call the physician. Urokinase is a thrombolytic medication used in the treatment of blood clots. It is given over 12 hours through an intravenous site. One of the severe side effects of urokinase is bleeding. The bleeding can be from any location, including internal bleeding in the abdomen that can result in bloody stools. Although the team will closely monitor the patient, the nurse should immediately stop the urokinase and call the physician for further orders.

You are caring for a patient with blood clots in his lungs. He is receiving urokinase for treating pulmonary embolism. The urokinase has been infusing for the last 10 hours. As you assess the patient, you note that his blood pressure is 102/64, heart rate is 108, and his respiratory rate is 16 breaths per minute. The patient asks to use the bedpan. When he is finished, you notice that he has passed a medium-sized bloody stool. Your best intervention is to: A. Closely monitor the patient B. Stop the urokinase and call the physician C. Administer Vitamin K intramuscularly D. Slow the administration of urokinase

Choice A is correct. As individuals age, they are at increased risk for senile cataracts. During the early stages of this condition, diminishing distance vision is the highest risk for older adults. The nurse must caution the patient that the ability to see signs when driving will present a significant risk.

You are working in a community clinic. You are giving instructions to a 72-year-old man who was diagnosed today with early bilateral senile cataracts. You know that the man understood your instructions when he says: A. "I may have to quit driving until I get the cataracts treated." B. "I am going to miss being able to read the morning newspaper." C. "My wife will have to pick out my clothes since I won't be able to see the colors." D. "I will have to be careful since my eyes won't move together."